btadlock1
Guest
I'm looking for official guidance to clarify a gray area in the Consultation guidelines...
Here's the situation:
A pediatrician sees a patient for a well check, and documents overall normal development. The patient's mother feels that the patient has developmental problems, and asks if the patient should see a specialist (documentation states that mother reports that the patient seems to have "mild OCD")- the pediatrician states that they don't think a specialist visit is warranted. The patient's mother insists on getting a specialist's opinion, and requests that the pediatrician give them a referral to a developmental psychologist (since insurance will not authorize the visit, without a referral).
The pediatrician requests the referral on behalf of the patient's mother, but makes no indication of their own concerns about the patient's development, in their documentation.
The developmental psychologist's notes are a bit ambiguous, and they make the mother's concerns, sound like the doctor's - they include choice phrases, like:
"C/C Referral from Dr. ___ for OCD"
HPI: "Pt is a 4yo male who is referred by Dr. ___ due to concerns about his development..."
And, at the end of the note:
"Copy sent to consulting physician."
Then, the psychologist bills a consultation code for the visit.
I have a problem with this being billed as a consult, because it's a misrepresentation of the circumstances of the visit - the "requesting" physician was not actually interested in getting the "consulting" physician's opinion, regarding the patient's development - they merely requested the referral, to appease the mother. But, the guidelines are just vague enough, to make it seem like a consult can be billed here, on a technicality. I think this should be treated like a regular referral, and billed as a new patient office visit, but I don't know if I'm right or not...
Does anyone know where I can find specific guidance on this type of scenario, to clarify whether or not this billing is allowed? (This actually involves one of my family members, and I want to help them out, but I have a rule against telling docs that they billed something incorrectly, unless I can back it up, first...)
Any help is greatly appreciated!
Here's the situation:
A pediatrician sees a patient for a well check, and documents overall normal development. The patient's mother feels that the patient has developmental problems, and asks if the patient should see a specialist (documentation states that mother reports that the patient seems to have "mild OCD")- the pediatrician states that they don't think a specialist visit is warranted. The patient's mother insists on getting a specialist's opinion, and requests that the pediatrician give them a referral to a developmental psychologist (since insurance will not authorize the visit, without a referral).
The pediatrician requests the referral on behalf of the patient's mother, but makes no indication of their own concerns about the patient's development, in their documentation.
The developmental psychologist's notes are a bit ambiguous, and they make the mother's concerns, sound like the doctor's - they include choice phrases, like:
"C/C Referral from Dr. ___ for OCD"
HPI: "Pt is a 4yo male who is referred by Dr. ___ due to concerns about his development..."
And, at the end of the note:
"Copy sent to consulting physician."
Then, the psychologist bills a consultation code for the visit.
I have a problem with this being billed as a consult, because it's a misrepresentation of the circumstances of the visit - the "requesting" physician was not actually interested in getting the "consulting" physician's opinion, regarding the patient's development - they merely requested the referral, to appease the mother. But, the guidelines are just vague enough, to make it seem like a consult can be billed here, on a technicality. I think this should be treated like a regular referral, and billed as a new patient office visit, but I don't know if I'm right or not...
Does anyone know where I can find specific guidance on this type of scenario, to clarify whether or not this billing is allowed? (This actually involves one of my family members, and I want to help them out, but I have a rule against telling docs that they billed something incorrectly, unless I can back it up, first...)
Any help is greatly appreciated!